2. The National System: Goals and Objectives

Abt Associates and its subcontractor, Partners Healthcare, with the assistance of a steering committee, was contracted to develop recommendations for a National Mass Patient and Evacuee Locating, Tracking, and Regulating System—referred to here as "the National System"—that could be used during a multi-jurisdictional mass casualty or evacuation incident to locate, track, and regulate patients and evacuees.  

For the purposes of this report, we will adopt the following terminology:

• A system that "locates" will provide authorized users with the ability to determine the current location and medical condition of a patient or evacuee.
• A system that "tracks" will provide authorized users with the ability to determine current and previous locations and medical conditions of a patient or evacuee or group of patients or evacuees.
• Regulating is a process that attempts to ensure that a patient or evacuee is transported on an appropriate vehicle (e.g., an airplane or an ambulance) to a location that has the staff, equipment, and other supplies that are needed to care for this person. Thus, a system that "regulates" will provide authorized users with a mechanism for assigning a patient or evacuee to a vehicle and then assigning a destination to that vehicle. 

By accomplishing these objectives, the National System will also support family reunification efforts and provide decision support to persons and organizations with responsibility for patient and evacuee movement and care, health care and transportation resource allocation, and incident management.

The Abt Associates project team was instructed to consider a National System that is as inclusive and comprehensive as possible. In that sense, "national" implies a nationwide geographic scope, rather than a level of government.  That is, the National System does not focus exclusively on patients and evacuees transported or cared for by Federal agencies. 

In the remainder of this section on goals and objectives, we refer to an ideal National System. It should be clear reading these sections that implementing an ideal National System is an enormous undertaking that will take several years to effect. Our recommendations, discussed in Section 3, therefore focus on an initial, Phase I system that by no means represents the ideal system but is nevertheless a platform on which the National System can be expanded and improved.

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2.1. Locating and Tracking

In terms of locating and tracking, an ideal National System would have a number of characteristics.  It would provide authorized users with access to information on any person affected by a multi-jurisdictional incident who seeks medical attention or is unable to self-evacuate to a safe area. Indeed, the Abt project team was instructed to consider all potential groups of patients and evacuees.  This would include persons who:

• Require medical attention as a result of a national disaster.
• Are at shelters operated by the American Red Cross or other organizations.
• Are in health care facilities that need to be evacuated.
• are in other overnight facilities, such as correctional facilities or hotels, that need to be evacuated.
• Require transportation out of the affected area with the assistance of a Federal, State, or local government agency or community-based organization.
• Are homebound and unable to receive assistance from family or friends.

As documented in Appendixes C and D, there are existing systems that can track a subset of these persons, at certain locations, in the event of a national disaster.  For example, the National Disaster Medical System (NDMS) uses a Department of Defense (DoD) system called TRAC2ES to track and regulate patients transported on DoD aircraft or other Federal transportation assets to NDMS-participating medical facilities.  The TRAC2ES system was activated during Katrina and was used to regulate several thousand evacuees during that disaster. A handful of municipalities have patient tracking systems that they use in mass casualties incidents to track patients from the incident scene to a hospital and possibly other locations. In addition, virtually any institution that houses patients or evacuees will have an automated system that "checks in" and "checks out" persons (Go to Appendix C—institutional records systems).  

An ideal National System would update location and health status information of patients and evacuees at any location where they are treated, housed, sheltered, or transported, in the same manner that package delivery companies "log in" a package when it is first picked up and then update the package's status as it enters or leaves a facility, is loaded on or taken off a plane or truck, and when it is finally delivered to its final destination. For patients and evacuees, these locations include:

• Overnight facilities for patients and evacuees, such as hospitals and shelters.
• Locations providing medical treatment, including temporary medical facilities, as well as hospitals, nursing homes, and other overnight facilities.
• Locations where patients and evacuees board or get off vehicles, such as airfields, train stations, bus stations, and piers.
• Other temporary gathering points for patients and evacuees.

As an illustration, consider a person who presented at a disaster shelter, became ill, and had to be transported to a hospital, was discharged and returned to the shelter, was evacuated out of the affected area to a reception area in another part of the State, and then was transported to a local shelter.  A database that tracked the location of this person might contain the following entries:

Date	Location	Event
10/15/07	Shelter XYZ	Arrive
10/17/07	Shelter XYZ	Depart
10/17/07	Hospital ABC	Arrive
10/19/07	Hospital ABC	Depart
10/19/07	Shelter XYZ	Arrive
10/23/07	Shelter XYZ	Depart
10/23/07	Bus 123	Board
10/23/07	Bus 123	Get off
10/24/07	Reception Area DEF	Arrive
10/24/07	Reception Area DEF	Depart
10/24/07	Bus XYZ	Board
10/24/07	Bus XYZ	Get off
10/24/07	Shelter ABC	Arrive

In addition to including all patients and evacuees and updating their status at any location where they are treated, housed, or transported, an ideal National System would also:

• Contain timely location and health status information that is updated as soon as possible after the patient or evacuee arrives at or leaves one of the locations noted above.
• Contain comprehensive medical information, so that health care professionals can provide appropriate medical care to patients and evacuees, who in all likelihood would arrive at a facility with little or no documented medical history; and,
• Ensure patient and evacuee confidentiality, adhere to all Federal privacy regulations such as the Health Insurance Portability and Accountability Act (HIPAA), and guard against domestic abusers or other predators (Appendix B). 

The above table also illustrates other potential uses for this information. Aside from the patient or evacuee locator function (i.e., "Where is John Doe right now?"), tracking information would: 

• Enable a hospital to determine the current location of all the patients that were evacuated from its facility.
• Alert health care professionals and emergency responders at reception centers to the medical condition of patients and evacuees who shortly will be arriving at their reception center; and,
• Enable public health officials to trace the movement of a patient or evacuee (and his or her contacts) who is later discovered to have a contagious disease.  

Aggregate patient and evacuee location and health status data also can inform incident commanders and public health and emergency response officials at the county, State, and Federal levels.  Thus, an ideal National System must be able to aggregate patient and evacuee data in a variety of ways, including:

• Patient and evacuee status, including the number of patients or evacuees, by health status, at various locations within a county, a multi-county region, a State, a multi-State area, or nationwide.
• Temporal trends, including daily or weekly trends in the number of patients or evacuees or the number of patients or evacuees by health status for the different geographic regions affected by the incident.
• Spatial trends, including how the geographic scope of the incident and the transport of patients and evacuees has changed since the start of the incident.

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2.2. Regulating

In a large scale or multi-jurisdictional disaster, regulating decisions are typically made on three levels:

• Group movement decisions to a region—e.g., a regulator decides to send 100 patients in an affected area to a reception center in a distant city. 
• Group movement decisions to a facility—e.g., a regulator at the reception center, who is anticipating arrival of the 100 patients, decides how many patients will be sent to each of the 12 hospitals in the city.
• Individual movement decisions to a particular facility on a specific vehicle—e.g., a person at the reception center, having been notified how many patients will be sent to each hospital, assigns individual patients to specific ambulances and tells the driver the destination hospital.

At the Federal level, the NDMS uses Federal Coordinating Centers (FCCs) to regulate patients from a disaster site to NDMS-participating medical facilities across the country.  There are roughly 70 FCCs across the country, which have relationships with local NDMS-participating hospitals and, in the event that NDMS is activated, determine the number of patients that each hospital can accept over a period of time.  DoD's TRAC2ES system notifies each FCC which patients are coming to their region.  Regulating is also performed at the State level, by persons who determine where patients or evacuees should be moved within the State. 

Clearly, regulating relies on complete, accurate, and timely information on the location and health status of patients and evacuees, including those in the affected area who need to be transported outside the affected area and those on their way to a particular location who will need to be cared for once they arrive.  In other words, an ideal National System that provides for patient and evacuee locating and tracking will also assist with the regulating process. 

In addition, effective regulating depends on resource availability information. An ideal National System would provide regulators with information on the availability of medical and transportation resources in:

• An affected area—e.g., to help determine whether sufficient assets are in the area to treat and transport patients and evacuees.
• Areas outside the affected area—e.g., to help determine potential locations to where patients and evacuees could be transported.

Information about resource availability is generally available in three forms: 

• Real-time availability at the unit level.  In this case, a regulator knows the real-time status of individual vehicles and has control over each vehicle's status (i.e., the regulator can assign a vehicle to a particular task).  Dispatchers in police or emergency response communication centers know the availability of each police or emergency medical service (EMS) unit in their jurisdiction. 
• Estimated number available at the "resource level." In this case, a location reports that they have a certain number of a particular resource available. AHRQ's Hospital Available Beds for Emergencies and Disasters (HAvBED) system provides a means for hospitals to report bed availability. Generally, the person receiving this information (e.g., the FCC receives bed availability information from NDMS hospitals) assumes that this number represents an estimate of the number available, rather than a guarantee that that number of beds are being reserved for them. 
• The number of resources in a location's inventory.  In the absence of the above two types of availability information, a baseline inventory number—combined with an expected capacity percentage—provides a rough estimate of resource availability.  For example, a 500-bed hospital assumed to be operating at 95 percent capability would ordinarily have 25 available beds at any given time (and could perhaps make more beds available during an emergency). 

In addition to providing complete and accurate resource availability information, an ideal National System could also assist regulating in the following ways:

• Automated notification of regulating decision.  Once a decision is made to move a group of patients or evacuees (or an individual patient or evacuee) to a location, persons with responsibility for transporting or providing medical treatment at that location could be notified automatically of the movement decision.  TRAC2ES provides this type of information to FCCs.
• Automated assignment of patients and evacuees to vehicles and locations.  Just as police and EMS computer aided dispatch systems recommend units to dispatch to calls for service (based on an "average expected location" for each unit), an ideal regulating system could offer decision support in the process of matching vehicles to patients and evacuees. This of course requires that the regulating system know the real-time availability of each vehicle.

As discussed later in Section 3, our recommendations focus on initial steps for improving regulating by improving the quality of availability information for a select group of key transportation and health care resources. 

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